Why have total cholesterol levels declined in most developed countries?

BACKGROUND Our paper addresses three major public health issues: cholesterol, statins and policies to prevent cardiovascular disease. DISCUSSION Total cholesterol levels in whole populations have fallen substantially in the USA, UK and most other developed countries. This has greatly contributed to decreases in cardiovascular disease deaths. The evidence identifying diet as the major contributor to these historical falls in cholesterol is powerful and consistent. Large falls occurred before statins were introduced. Additional substantial falls occurred before statins were widely used.Now, up to 14% adults in Western populations currently receive statins for primary prevention. Furthermore, because diet is now only slowly improving, the statin contribution currently appears proportionately larger. SUMMARY In conclusion, diet change explains most of the historical falls in cholesterol. Until very recently, the contribution from statins has been surprisingly modest. Furthermore, many middle income countries may have neither the resources nor the infrastructure for mass statin therapy.Further substantial falls in cholesterol are therefore unlikely to be obtained simply by increased use of statins or dietary advice to individuals if unsupported by the wider environment. This further emphasises the need for more effective structural policies. Regulatory and fiscal interventions could easily eradicate industrial transfats, halve the intake of dietary saturated fat, and subsidise healthier fats.